DECLARATION OF AN ACCIDENT AT WORK / A COMMUTING ACCIDENT

The declaration must be completed, according to the instructions, by the employer or his representative.
1. EMPLOYER
1.01 Name of the company, the administration or first and last name of the employer

1.02 Address

1.03 Employer's social security number

2. INSURED
2.01 First and last name of the insured 2.02 Social security number of the insured

2.03 Address

2.04 Temporary worker? If applicable, name of the temporary employer If applicable, social security number of the temporary employer
Yes No
2.05 The insured works :
Full-time Part-time Please indicate the regular number of hours worked per week hours / week
2.06 Insured's occupation (e.g. painter, teacher, accountant)

3. INFORMATION CONCERNING THE ACCIDENT

3.01. Date and time of the accident 3.02. Date and time of reporting to the employer or his representative

: :
day / month / year H m day / month / year H m
morning from / to afternoon from / to
3.03 Hours during which the insured worked or should
have worked the day of the accident
: / : : / :
H m H m H m H m
3.04 Did the accident occur : In case of a road accident :
- was the insured in :
at the regular workplace
a company car a private car other
at an occasional or mobile workplace
- was the insured :
while commuting the driver the passenger other

Please indicate the address of the workplace if different from 1.02 : - was a friendly accident report filled out?
Yes No

- was a police report established?

Yes No

3.05 Detailed description of the location or the insured's workplace when the accident occured (in case of a road accident, please specify the exact location: e.g. locality,
street, motorway exit, etc.) In case of an accident abroad, please indicate the country.

3.06 Detailed description of the activity or task the insured was performing at the moment of the accident.

3.07 List of objects involved in the accident (e.g. tools, machines, equipment, materials, instruments, substances, etc.).

3.08 Description of events that deviated from the normal process and led to the accident (e.g. wet or slippery floor).

3.09 If applicable, please specify the public authority (e.g. Police, ITM, CGDIS, ...) which was notified / was on site of the accident :

3.10 Was(Were) there any eyewitness(es) ? If applicable, name(s) and address(es) of the witness(es)
Yes No

3.11 Name, address and function of the first person notified in the company

vers.2.01 (code F 1.1) page 1/2

 4. PREVENTIVE MEASURES
4.01 Which preventive measures were in place when the accident occurred?

4.02 Which preventive measures have been taken or should be taken in order to avoid a similar accident in the future?

5. CONSEQUENCES OF THE ACCIDENT ACCORDING TO THE INSURED'S INFORMATION

5.01 No injury, only material damage to the vehicle -> Please continue with point 6.
5.02 In case of injury, please indicate the nature of the injury(ies)
Superficial wounds and injuries Effects due to noise, vibration and pressure

Bone fractures Effects due to extreme temperature, light or radiation

Dislocations, sprains and strains Shock (emotional / psychological)

Concussions and internal trauma Burns and frostbites

Other injury(ies), please specify:

5.03 Please indicate the location of the injury(ies)

Head Eye(s) left right

Neck Shoulder(s) left right

Back Arm(s), including elbow(s) left right

Chest Hand(s) left right

Stomach, pelvis Leg(s), including knee(s) left right

Foot / feet left right

Other injured body part(s), please specify:

5.04 If applicable, name and address of the first attending physician

Date of consultation : Doctor code (if known) : -

day / month / year
5.05 If applicable, name of the hospital attended

5.06 Consequences of the injuries The insured :

Death of the insured
resumed work on
The insured did not interrupt his work day / month / year
did not resume work
The insured left work on
Please indicate the end of the expected disability on the certificate of work
incapacity (if known)
at :
day / month / year H m day / month / year
6. SIGNATORY (EMPLOYER OR REPRESENTATIVE)
6.01 First and last name of the employer or his representative

6.02 Function of signatory 6.03 Telephone number

6.04 By checking this box, I wish to express my doubts regarding the truth of the facts. I am required to attach a detailed statement of doubt.

6.05 Place and date

, the
Please fill out all the sections before sending this form by computer or if it is filled by
hand with black ink in capital letters.
day / month / year
6.06 Signature of the employer or his representative Any incomplete form will be returned !
The declaration must be sent to Association d'assurance accident,
either to the postal address L-2976 Luxembourg,
by fax to the number +352 495335 or
by e-mail (PDF format) to the address
declaration.aaa@secu.lu
vers.2.01 (code F 1.1) Print page 2/2